The primary purpose of the job is to: Working with the Operations Supervisor or Grievance Coordinator, the Grievance Associate is responsible for ensuring all problems, complaints and grievances, presented by Plan members or their representatives are resolved in accordance with established policies and procedures as well as, NCQA and Federal/State guidelines. Under the supervision of the Operations Supervisor or Grievance Coordinator, the Grievance Associate acts as a member advocate and communicates with medical facility administrators, providers, physicians and all applicable AMFC departments to interpret and enhance understanding of the Plan’s policies and procedures relative to complaints and grievances. The Grievance Associate is responsible for accurately documenting, in the appropriate computer system, all correspondence associated with the grievance. The Grievance Associate will thoroughly research questions and issues in order to provide an accurate explanation. The Grievance associate tracks and reports turnaround time and keeps abreast of all cases to ensure that the 30-day time limit for case resolution is met for 100% of all grievances. The associate will provide Complaint/Grievance training for the Plan’s staff in the base unit and all supporting departments. The Grievance Associate will perform other related duties and projects as assigned.
•One to three years previous experience in direct contact with members in relation to any complaints and/or grievances •Sound knowledge of strong telephone soft skills. •Prior experience in highly regulated inventory •Experience with Contact Center and Workforce Management technology (scheduling, adherence, quality monitoring) •Excellent Verbal and Written communication skills. •Microsoft Office skills including Word, Excel and Outlook •Experience handling escalated calls •Demonstrated problem-solving and decision making skills. •Strong people skills with a focus on mentoring and coaching •Ability to work both independently and in a team environment